ankle x rays

7/27/2019 Ankle X Rays

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X-Ray Rounds:

(Plain) Radiographic Evaluation

of the Ankle

Garry W. K. Ho, M.D.VCU / Fairfax Family Practice

Sports Medicine Fellow

September 2006


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Anatomy

Complex hinge joint

Articulations among:

Fibula

Tibia

Talus

Tibial plafond

Distal tibial articularsurface

Complex ligamentoussystem


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Anatomy

Medial malleolus

Distal tibia

Medial support

Lateral malleolus Distal fibula

Lateral support

Talus

Trapezoid-shaped

Mortise (tibial plafond, medial & lateral malleoli)

- Constrained articulation with the talar dome


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Anatomy

Syndesmotic ligamentcomplex

Axial, rotational, &translational stability

Four ligaments:Anterior tibiofibularligament

Posterior tibiofibularligament

Transverse tibiofibularligament

Interosseous ligament


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Anatomy

Deltoid (medial)ligament complex

Superficial (contributes

little to stability)Tibionavicular ligament

Tibiocalcaneal ligament

Superficial Tibiotalarligament

Deep (primary medialstabilizer)

Intraarticular:

Deep tibiotalarligament


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Anatomy

Lateral (fibularcollateral) ligamentcomplex

Anterior talofibular

ligament (weakest) Posterior talofibular

ligament (strongest)

Calcaneofibularligament


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Indications for Ankle Radiographs

Ottawa Ankle Rules Age 55 years or older


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Indications for Ankle Radiographs

How good are the Ottawa Rules? When originally published:

100% sensitivity & 40% specificity for detectingmalleolar fractures

Subsequent studies:

Lower sensitivity (93% to 95%) and specificity (6%to 11%) than originally thoughtNot perfect, but still a good tool

Other indications The patient cannot communicate (altered

mental status, alcohol intoxication, or other) Pain and swelling do not resolve within 7-10

days after injury Anytime your history and physical dont give

you enough information


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Normal ankle(AP view)

Normal ankle(Mortise view)

Normal ankle(Lateral view)


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AP View of the Ankle

DE: Talar Tilt: < 2 degrees of angulation is Nl

D

E


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AP View of the Ankle

Talar Tilt: > 2 degrees angulation mayindicate medial or lateral disruption

Tib-fib Clear Space > 5mm orTib-fib Overlap < 10mm

may indicate syndesmotic injury


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Lateral View of the Ankle

Dome of the talus:centered underand congruouswith tibial plafond

Posterior tibialtuberosityfractures &direction offibular injuries

can be identified

Avulsionfractures of thetalus by theanterior

capsule can beidentified

Anydeformity tothe talus,calcaneusor subtalar

joint


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Calcaneal Fractures

Bohlers Angle

30-35 degreesis normal

Others:

Critical Angleof Gissane

BrodensViews


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Mortise View of the AnkleAP view taken with the footin 15-20 degrees of internal

rotation to offset theintermalleolar axis

Medial clear space > 4mm may indicate

lateral talar shift

Talar tilt, Tib-fib Overlap,Tib-fib clearspace (see APview)

Talocrural angle (angle b/wplafond parallel andintermalleolar line) Normal is 8-15 degrees

(where the lines intersect) Smaller angle may indicate

fibular shortening


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Mortise View of the Ankle


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mm

Normal AP &lateral rightankle X Ray


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mm

AP View:

Widened medialclear space

Mortise View:

Open mortise(decreased tib-fiboverlap)

= Syndesmotic

injury

= Surgical referral

(needs a screw)


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28 y/o M whotwisted his leftankle while playingbasketball 1 day

ago

Danis-Weber Type B fibularankle fracture


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Ankle Fracture Classification

Danis-Weber Classification Defined by location of the

fracture line

Type A: below the

tibiotalar jointType B: at the level of thetibiotalar joint

Type C: above thetibiotalar joint

Syndesmotic ligamentcompromise

Lauge-HansenClassification Infrequently used,

clinically; mostly academic


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mm

Mortise view:

Weber C fracturewith open mortiseand widenedmedial clear space

= deltoid &syndesmoticligament tears,with fracture

= surgical referral


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mm

25 y/o volleyballplayer landed wrongon the right foot,

hurting the ankle

Exam with positivetalar tilt

Lateralligamenttears

-ATFL

-CFL


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Radiographic Stress Tests of the Ankle

Talar Tilt Stress Test

Stabilize the leg with onehand while inverting plantarflexed heel with the other

Contralateral ankle used forcomparisonLine is drawn across thetalar dome and tibial vault

Degree of lateral openingangle is measured Normal tilt is less than 5

deg

Standing Talar Tilt StressTest:

may be more sensitivePatient stands on aninversion stress platformwith the foot and ankle in40 deg of plantar flexionand 50 deg of inversion


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Grade IIIATFL anklesprain

25 y/o male tennisplayer torqued hisright ankle

Exam with positiveanterior drawer sign


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Radiographic Stress Tests of the Ankle

Anterior Drawer Test Abnormal anterior

translation is between 5to 10 mm, or 3 mmmore than other side

External Rotation StressTest

Evaluates syndesmotic &

deep Deltoid ligaments Difference in width of

superior clear spacebetween medial and lateralside of the joint should be< 2 mm


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mm

AP View:

Widenedmedial clearspace

Decreased tib-fib overlap

= Medial &syndesmoticligamentcompromise

= surgicalreferral


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mmNormal AP &lateral views

Open mortise

= needs a screw


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mm

Weber Type Alateral malleolar

fracture

Treat conservatively


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mm

Open mortisewith high fibularfracture

Name?

Maissoneurve

fracture

= surgicalreferral


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mm

Salter-Harrisfracture, type II

= Refer for ORIF


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S A L T ERStraightAbovebeLowThroughCERush1 2 3 4 5


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mm

Lateral ligamentousinjury

Medial malleolaravulsion fracture

Surgical referral


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mm

Nondisplacedspiral fibularfracture

= CR &immobilization


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mm

Posterior malleolaravulsion fracture


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mm

AbnormalBohlers angle

= Calcaneal Fx

Surgerize!


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mm

Medial malleolarfracture

= refer for screwfixation


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mm

Medial malleolar Fx

Widened medialclear space: talardislocation

Open mortise:syndesmotic injury

Maissoneurve Fx

= Surgery


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mm

Bimalleolar fractures

Osteopenic appearingbone

Surgical referral

Tx osteoporosis prn


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mm

Diagnosis?

Charcots foot


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mm

Anterolateral

tibial epiphysealfracture

aka: Tillauxfracture


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Tillaux Fracture

Fracture of theanterolateral tibialepiphysis

Mechanism

Avulsion of epiphysealfragment due to thestrong anteriortibiofibular ligament

External rotational forceacross the ankle

Commonly seen inadolescents

Treatment: ORIF


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mm

Calcanealosteomyelitis

= IV Abx

= Surgical I & Dif chronic


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mm

Calcanealfracture

= ORIF

M ti i


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mm

Mortise view

AP view

Lateral view

Pilon fracture(Comminuted tibial

plafond compressionfracture)

Management?


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mm

Positive talar tiltstress test

Surgery

/ F ll hil k li bi


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s/p Fall while rockclimbing Treatment ?


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Conclusion

Plain radiographicanatomy of theankle

Indications forplain radiographsof the ankle

Direct and indirectsigns of injury onplain radiographs

h d


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The End

ankle x rays

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